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Resident Orientation Manual

Produced by Galveston Shriners Burn Hospital and
The University of Texas Medical Branch Blocker Burn Unit.
Contributors:  Sally Abston MD, Patricia Blakeney PhD, Manubhai Desai MD,
Patricia Edgar RN, CIC,John P Heggers PhD, David N Herndon MD,
Marsha Hildreth RD, Ray J Nichols Jr. MD

ACUTE STRESS DISORDER (ASD) and POST-TRAUMATIC STRESS DISORDER (PTSD)

   Pharmacological management of Acute Stress Disorder (ASD) and Post-Traumatic Stress Disorder (PTSD) symptoms can be the most helpful intervention in acutely burned children.  Symptoms commonly described by children and parents include nightmares, flashbacks (re-experiencing the trauma while awake), difficulty falling asleep, difficulty staying asleep, hyper-vigilance, startle response, and dissociative feelings.

1)  Please contact the Psychologist-on-call.  ASD/PTSD assessment will be conducted prior to beginning therapy and will access possible consent to participate in study, "Evaluating Effectiveness of Imipramine and Fluoxetine in Treating Pediatric Burn Patients with Symptoms of Acute Stress Disorder".

Post-consent write orders -
"Study drugs are as follows:
Fluoxetine Study dose PO qam at 08:00 hours
Imipramine Study dose PO qhs at 20:30 hours"

2)  Dosage and Monitoring of Imipramine, a Tricyclic Anti-depressant (TCA)

a.  Imipramine dose:  1 mg/kg/dose - administer at bedtime (20:30 hours)
     Imipramine is available only as a 10mg, 25mg, and 50mg tablet and as a 100mg and 150mg capsule.  Not available in a liquid form.

b.  Advance dose based on levels or PR interval (<0.2).

c.  Draw levels starting one week after imipramine is begun and draw level exactly 8 hours at 05:00 hours the next morning after bedtime dose is given at 21:00 hours the night before.
    Combined imipramine and its demethylated metabolite, desimipramine, levels:
    Therapeutic = 150-300 ng/ml total
    Toxic = >500 ng/ml total

3)  Dosage of Fluoxetine, a Selective Serotonin Reuptake Inhibitor (SSRI)
     Fluoxetine dose:  Administer in the morning (08:00 hours)
       5mg for patients < 40kg
     10mg for patients > 40kg and < 60kg
     20mg for patients > 60kg

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